In The Venue

Bipolar disorder is a treatable illness marked by extreme changes in mood, thought, energy and behavior.  These changes in mood, or “mood swings,”  are of variable length,  and can last anywhere from hours to months.

Sometimes people experience symptoms of mania and depression simultaneously. During this state, known as mixed mania, they have all the negative emotions that come with depression, such as hopelessness, pessimism, and a sense of worthlessness, but they are also agitated, restless and full of nervous energy.   Nowhere is it truer than for people in a mixed state that there is “no rest for the weary.”

There are several forms of bipolar disorder.  The patient with Bipolar I Disorder, the most severe, experiences one or more major depressive episodes and one or more episodes of mania or mixed mania, defined in the DSM-IV as symptoms of both a mania and a depression occurring daily for at least one week.  The hallmark of Bipolar I Disorder is the severity of the manic episodes, during which patients may become aggressive, impulsive and sometimes delusional.

Bipolar II Disorder is a milder condition, in which a patient has had at least one major depressive episodes and at least one episode of hypomania.  The latter includes all the symptoms of mania with the exception of delusions and hallucinations.   People with Bipolar II Disorder may also experience periods of relative calm between their manic and depressive episodes.  Because the highs in hypomanias of Bipolar II are not as high as the manias of Bipolar I, patients may not recognized them or report them, and their Bipolar II disorder may get misdiagnosed as major depression.  People with Bipolar II have recurring and easily recognizable depressions that come and go periodically but they have also experienced periods of at least four days at a time when they felt especially or abnormally energetic or irritable, self-confident, social, talkative, irritable and quickly angered.  They may have also been thinking faster than usual, had trouble concentrating, been more goal oriented and productive, and indulged in more pleasurable activities such as shopping and sex.  Their friends and loved ones might also have been commenting that they seemed to be acting out of character.

A diagnosis of Bipolar Disorder with Rapid Cycling describes patients who experience at least four episodes of mania or depression in one year.  Rapid Cycling can occur with any either Bipolar I or Bipolar II, and is often a temporary response to stress.

The DBSA (Depression and Bipolar Support Alliance) has found that misdiagnoses of Bipolar are extremely common, in part because many people don’t report all of their symptoms.  They misunderstand their own hypomanic episodes as  “really good days” and don’t report them because they didn’t feel like an illness.  Nearly 70% of people with bipolar disorder are misdiagnosed at least once, and they must wait 10 years on average between the time they have their first bipolar symptoms and the time when they get correctly diagnosed and treated.

Almost six million adult Americans, close to 2% of the country’s population, have some form of bipolar disorder.   While some children and adults do experience the symptoms for the first time,  bipolar usually hits in the teen years and begins as depression.   Men and women develop the condition in equal numbers, although for women it tends to begin with depression and for men with a manic episode.  Bipolar disorder, moreover, is an equal opportunity offender that hits people not only at all ages, but also in all races, ethnic groups, and social classes. However, it does not occur randomly.  Rather, it tends to run in families and probably has a genetic component. If it is untreated, bipolar disorder comes and goes, much like chronic body disorders such as Crohn’s disease; this is one of the reasons that the condition is probably underdiagnosed.   At the same time, no treatment for bipolar can eliminate the disease completely.  Even patients on medication will have mood swings occasionally.     Nonetheless, the treatments are to a large degree effective.  People with untreated bipolar disorder have much more frequent recurrences of mood cycles than bipolar people on medication.

Although another mood disorder, clinical depression, has symptoms similar to those of the depressive phase in bipolar disorder, the two illnesses are different in that people with bipolar disorder experience often-severe swings between manic “highs,” when they feel extremely energetic, and depressive “lows” when they feel deep despair.   People with clinical or “unipolar” depression, on the other hand, experience depressive “lows” but not manic “highs.”  The emotional ups and downs of bipolar disorder is also distinct from the normal mood changes of healthy people because the swings cannot be controlled by will power alone, and they disrupt the normal routines of life.

People with bipolar disorder experience the lows of bipolar depression more often than the highs — mixed mania, mania or hypomania. Because bipolar depression can also be more disabling than mania, and it is associated with suicidal thinking and behavior, people with bipolar disorder are more likely to seek out help and get diagnosed during a depressive phase.    For this reason, between 10 and 25% of the “outpatient” population are misdiagnosed with unipolar or clinical depression by their primary care physicians, and when patients enter a psychiatric hospital, the percentage of misdiagnosed cases is even higher.  Misdiagnosis is a serious problem because different medications are prescribed for unipolar and bipolar disorder.  A person with bipolar who takes antidepressants can have an induced manic episode, as well as other problems.

Bipolar disorder, therefore, is probably underdiagnosed.  Nonetheless, it is essential for doctors and psychiatrists to rule out other possible causes of extreme mood swings, which can include head injuries, thyroid problems, HIV, diabetes, ADHD, eating disorders, schizophrenia, and even the side effects of certain medications, because other conditions are treated with different medications.   Since no lab test exists for bipolar disorder, psychiatrists are obliged to make the diagnosis based on a careful discussion of the patient’s mood changes.

The depressive state is a more painful experience for patients than manic episodes, during which the mood is one of euphoria and aggression.  And yet, although it feels good, mania is dangerous both for the patient and for others.  Patients with severe mania usually require hospitalization to prevent them from highly impulsive, reckless or risky behavior.  Depressed patients, too, may need to be hospitalized because they may act on their suicidal thoughts.   Since both poles of bipolar are dangerous to the patients’ health, it is no surprise that 90% of individuals with bipolar I disorder have been hospitalized at least once, and two thirds will have two or more hospitalizations in their lifetime.